Faculty Bibliography

LEARNING OBJECTIVES/OBJECTIVE:After studying this article, the participant should be able to (1) gather appropriate history and perform relevant physical exam maneuvers for head and neck complaints, (2) relate presenting complaints to differential diagnoses, (3) describe the appropriate workup for various head and neck complaints and presentations, and (4) perform clinical staging of head and neck tumors according to current guidelines. SUMMARY/CONCLUSIONS:Pediatric head and neck cancers are rare and complex, but plastic surgeons may play a crucial role in the multidisciplinary and multifaceted workup of a suspected malignancy. These cancers present unique diagnostic and therapeutic challenges given the unique anatomy, physiology, and developmental considerations in children compared to their adult counterparts. A comprehensive workup for pediatric head and neck malignancies is essential, starting with taking a thorough history and physical exam, followed by a well-considered and wide differential diagnosis. Appropriate imaging modalities and biopsy techniques are pivotal in obtaining an accurate diagnosis. Tumor and site-specific staging seek to provide essential information for guiding treatment planning. Plastic surgeons, therefore, must be informed and well versed in their evaluation and workup to best optimize patient outcomes.

BACKGROUND:Whole eye transplantation (WET) has long been looked to as a potential solution for the aesthetic and functional deficits caused by severe ocular pathology and trauma. Here, we describe the first successful combined face and whole eye transplantation (FT/WET), highlighting the logistical, ethical, and technical considerations that enabled this milestone. METHODS:A 46-year-old male with severe facial and ocular deficits underwent multidisciplinary evaluation and was deemed a candidate for FT/WET. Subsequently, a surgical algorithm was developed through rigorous preoperative planning and team based surgical simulations. This process focused on techniques that would allow for efficient graft procurement and inset, while simultaneously limiting trauma to the globe and its adnexa. RESULTS:Longitudinal monitoring demonstrated maintained graft viability throughout the postoperative period. Fluorescein angiography and ICG angiography confirmed robust retinal and choroidal perfusion. Diffusion-weighted MRI revealed structural preservation of the optic tracts, despite inner retinal atrophy. The patient has also experienced significant improvement in facial aesthetics and functionality with no episodes of graft rejection to date. CONCLUSIONS:This case demonstrates the feasibility of addressing deficits once deemed irreparable through advanced surgical techniques, preoperative planning, and multidisciplinary collaboration. Although functional vision recovery has not been observed, this innovation expands the reconstructive options available for patients with severe facial and ocular deficits, paving the way for future advancements in vascularized composite allotransplantation.

BACKGROUND:Congenital palatal fistula (CPF), most often associated with submucous cleft palate (SMCP), is a rare clinical entity. Surgical management is challenging owing to anatomical variation and risk of persistent velopharyngeal insufficiency (VPI). We reported outcomes from a case series of 27 patients with CPF associated with SMCP managed using a standardized institutional algorithm. METHODS:A retrospective review was conducted at CLAPP Hospital, Lahore, from 2015 to 2020. Patients with CPF associated with SMCP were included; acquired fistulae and syndromic cases were excluded. Fistulae were classified using the Pakistan Comprehensive Fistula Classification Scheme. SMCP was further stratified according to the CLAPP Classification and Treatment Algorithm, guiding surgical approach (midline incision, modified Langenbeck, or standard Langenbeck with/without adjunctive procedures). Outcomes included fistula recurrence and speech results. RESULTS:The cohort comprised 27 patients (mean age 9.9 years; range 1-23 years), and 52% were female. Two patients (7.4%) developed postoperative fistula recurrence. Preoperatively, 94% of patients had severe hypernasality (G3). Postoperatively, mean composite speech scores improved by 52.3% (14.9→7.1). Fourteen patients [14/17 (82.4%)] achieved G0/G1 (normal resonance). Younger patients (<12 years) showed greater improvement (90% to G0/G1) compared to older patients (71.4%). No middle-ear sequelae were observed. CONCLUSIONS:A tailored algorithmic approach for CPF associated with SMCP yielded low recurrence (7.4%) and substantial speech improvement. Younger patients demonstrated greater postoperative speech benefit, underscoring the importance of early diagnosis and repair.

Cleft lip and/or palate (CL/P) is a life-long condition that requires multidisciplinary care throughout childhood and beyond. Studies have examined the impact of CL/P on psychosocial outcomes including lower self-esteem, higher incidence of bullying, social isolation, and rejection. As a result, patients may be predisposed to experiencing mood disorders or trauma related to their facial difference. Moreover, access to dedicated cleft centers is limited in many areas in the United States. For children with a CL/P who present to the healthcare system, evaluating for trauma symptoms and incorporating trauma-informed care can support these patients' psychosocial wellbeing during an impressionable developmental period.

Presurgical lip, alveolus, and nose approximation (PLANA) is a novel form of presurgical infant orthopedics (PSIO) designed without an intraoral molding plate. While early studies on PLANA have demonstrated improvements in nasolabial morphology, its impact on infant feeding and weight gain has not been assessed. A single-institution, retrospective review of all patients with cleft lip and palate (CL±P) treated with PLANA over a 1-year period was therefore performed. Weight values at baseline and at surgery were compared with World Health Organization (WHO) Child Growth Standards, and weight-for-age z-scores (WAZ) as well as changes in weight-for-age z-scores (WAZ) were obtained. A cohort of patients who underwent PSIO with NasoAlveolar Molding (NAM) was evaluated as a reference group. The PLANA (n=19) and NAM (n=25) groups were comparable in age (15.63 versus 21.16 d, P=0.2), weight (3.38 versus 3.50 kg, P=0.2), and WAZ (-0.80 versus -0.94, P=0.8) at baseline, and in age (103.11 versus 113.04 d, P=0.06), weight (5.82 versus 5.68 kg, P=0.3), and WAZ (-0.92 versus -1.47, P=0.2) at surgery. Both groups had similar weight gain (2.44 versus 2.18 kg, P=0.1) and WAZ (-0.12 versus -0.53, P=0.2). The PLANA group exhibited statistically significant greater daily weight gain (0.028 versus 0.024 kg/d, P=0.04). None of the patients experienced surgical delays due to insufficient weight gain. PLANA did not interfere with presurgical weight gain in infants with CL±P.

Strict trainee work-week hour restrictions, increased complexities of surgical care, and shifting hospital policies have posed challenges to operating room training for residents in high-resource regions. A shortage of cleft-trained surgeon educators and inconsistent training curricula further limit exposure to cleft operative education in low-resource settings. Furthermore, teaching cleft surgery can be difficult given the confined space of the infant oral cavity and the small, delicate flaps used for reconstruction. In the face of these challenges, the role of simulation has expanded in surgical education to supplement intraoperative training and increase resident preparedness. Smile Train, a nonprofit cleft-focused organization, in partnership with the technology companies BioDigital (New York, NY) and Simulare Medical (Toronto, Ontario, Canada), and academic plastic surgeons, has developed and globally distributed a variety of simulation resources for cleft surgery. This work provided a comprehensive review of Smile Train-distributed simulator modalities, including surgical training videos, a digital simulation platform, high-fidelity physical simulators, and virtual reality models. This review described the evolution of these models, the effects on learner experience, knowledge, and surgical performance, as well as directions for future development.